Medical Summary - Non-Union Service HAP HMO Plan PREVENTIVE SERVICES - *UNLIMITED PER MEMBER PER CALENDAR YEAR Health Maintenance Exam includes chest X-ray, EKG and select lab procedures Annual Gynecological Exam Pap Smear Screening lab services only Well-Baby and Child Care Immunizations Fecal Occult Blood Screening Flexible Sigmoidoscopy Exam Prostate Specific Antigen (PSA) Screening Colonoscopy - no age restrictions Routine Mammography Screening no age restrictions PHYSICIAN OFFICE SERVICES Office Visits Outpatient and Home Visits Office Consultations EMERGENCY MEDICAL CARE $15 copay $15 copay - $15 copay Hospital Emergency Room approved 100% diagnosis $100 copay Urgent Care Center 100% $30 copay Ambulance Services medically necessary 100% DIAGNOSTIC SERVICES Laboratory and Pathology Tests 100% Diagnostic Tests and X-rays 100% Radiation Therapy 100% MATERNITY SERVICES PROVIDED BY A PHYSICIAN Pre-Natal and Post-Natal Care $15 copay Delivery and Nursery Care 100% HOSPITAL CARE Semi-Private Room, Inpatient Physician/ 100% General Nursing, Hospital Services and Supplies Inpatient Consultations 100%
Medical Summary - Non-Union Service HAP HMO Plan Chemotherapy 100% ALTERNATIVES TO HOSPITAL CARE Skilled Nursing Care 100% up to 730 days, renewable after 60 days Hospice Care 100% Home Health Care 100% SURGICAL SERVICES Surgery (includes related surgical services) 100%; Bariatric surgery and related services subject to a $1,000 copay Voluntary Sterilization 100% MENTAL HEALTH CARE AND SUBSTANCE ABUSE Outpatient Mental Health Care Outpatient Substance Abuse Care (approved facilities only) $15 copay $15 copay Inpatient Mental Health Care and Substance Abuse Care OTHER SERVICES Allergy Testing and Therapy (in physician s office) Chiropractic Spinal Manipulation Outpatient Physical, Speech and Occupational Therapy DEDUCTIBLE, COPAYS AND DOLLAR MAXIMUMS Annual Deductible Annual Out-of-Pocket Maximums (includes deductible) PRESCRIPTION DRUGS Prescription Drug s Retail Includes Contraceptives Prescription Drug s Mail Order (90 day supply). 100% 100% Not covered 100%, 60 visits per person per benefit period None None $10 Generic $20 Brand Maintenance drugs: 1 x copay Non-Maintenance drugs: 3 x copay less $5
Dental Coverage Non-Union Service Preventive & Basic Services Office visit - twice per calendar year (CY) Cleanings - twice per calendar year Restorations (fillings) Sealants (up to and including age 14) every 36 months Fluoride treatment (up to and including age 18) twice per CY Space maintainers (up to and including age 18) twice per CY X-rays (bitewings) - twice per year X-rays (full mouth and panoramic) every 36 months Oral Surgery Periodontics (gum disease) Endodontics (root canals) Extraction of Teeth Inlays / Onlays and Crowns Local Anesthetics Major Services Implants Bridges (full or partial) Dentures In-Network DNoA Provider or Blue Par Select 1 85% of approved amount 85% of approved amount maximum for services shown above per calendar year $1,500 Orthodontia (to age 19) Habit breaking appliances Minor tooth guidance appliances Full banding treatment Monthly, active treatment visits 85% of approved amount Out-of- Network Provider 75% of reasonable & customary 75% of reasonable & customary 85% of reasonable & customary Lifetime benefit maximum for orthodontia services $1,700 1 Members receive the deepest discounts when utilizing DNoA PPO providers. Members can also utilize Blue Par Select providers (larger network) and receive some discounts with no balance billing. Dentists who participate in neither network can balance bill members.
Vision Plan Summary Non-Union Vision Exams ITEM Single Vision Lenses Bifocal Lenses Trifocal Lenses IN-NETWORK ONLY BENEFITS UNITEDHEALTHCARE SPECIALTY BENEFITS at 100% once in a calendar year at 100% once in a calendar year at 100% once in a calendar year at 100% once in a calendar year Lenticular Lenses at 100% once in a calendar year Additional Services Sunglasses / Tints UV Coating Polycarbonate Lenses Anti-Reflective Coating Edge Coating Transition Coating Photochromatic Coating Progressive Lenses Scratch Resistant Coating Eyeglass Frames up to 100% once in a calendar year Applicable allowance depending on whether the frames are acquired through an independent or retail provider. Contact Lenses, in lieu of glasses Lasik Eye Surgery Miscellaneous up to the following once in a calendar year: Select Contacts at 100%. Includes 4 boxes of disposable contact lenses, evaluation, fitting, and 2 follow-up visits for select contacts Non-Select Contacts at 100% up to $105 reimbursement. Examples of Non-Select contacts are toric, gas permeable, and bifocal Available at a discount No claim forms are required There is no outlay of cash for covered services up to the maximum benefit There is no balance billing Basic Life/AD&D Summary Non-Union Amount / Life 1 times salary to a maximum of $50,000 Reduction Schedule Basic Life: None Basic AD&D: None
Voluntary Short Term Disability Coverage Non-Union Elimination Period (period of disability before Short Term Disability benefits are payable) Accident, Hospital Confinement or outpatient surgery 14 days of disability Sickness - 14 days benefits are payable on the 15th day 60% of earnings Amount Weekly Maximum $600 Duration of Period 24 weeks (4 weeks when pre-existing condition applies) Offsets State disability benefits, No-fault motor vehicle disability income, Family social security benefits Long Term Disability Non-Union Eligibility Elimination Period Maximum Period Amount Offsets Each regular full-time employee 180 days (or greater of accrued sick leave) To age 65 or 3 years, whichever comes first 60% of covered earnings to a maximum of $1,350 per month s may be offset by the following: Canada and Quebec Pension Plans Railroad Retirement Act Government disability or retirement plan Sick leave or salary continuation plan of the Employer No-fault auto insurance Workers compensation Occupational disease Unemployment compensation law or similar state or federal law Social Security disability or retirement benefits Retirement Plan benefits funded by the Employer Franchise or group insurance or similar plan
Flexible Spending Accounts Non-Union Health Care Reimbursement Account (HCRA) Annual Maximum: $3,000 Dependent Care Reimbursement Account (DCRA) Annual Maximum: $5,000